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SWRCB, January 2002 Page 1 of 1 <br />Secondary Containment Testing Report Form <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems.se thea propriate <br />pages of this form to report results for all components tested. The completed form, written test procedures, and p <br />applicable), should be provided to the facility owner operator for submittal to the local regulatory agency. f IECEIVE <br />n. - <br />I FACILITY INFORMATION <br />Facility Name: CFLEVRON 210997 (N-4693) jDate of Testing: 213/2014 L. <br />Facility Address: 1442A COLONY DR. , RIPON, CA 95366' <br />Facility Contact: PATTY Phone: 209-599-0149 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during tcsting)i twie <br />2- TFSTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY LNC. <br />Pass <br />Technician Conducting Test: Jarrod Cooke <br />Not <br />"bested <br />Credentials: 7 CSLB Licensed Contractor <br />t— SWRCB' Licensed Tank Tester <br />License Type: a <br />Manufacturer <br />ILicense Number: 743160 <br />Manufacturer Training <br />Component(s) Date Training Expires <br />tanknology <br />all 5/16/2014 <br />Spill Box T (:SUPREME UNLEADED premium <br />fill <br />- A <br />II— <br />3. SUMMARY OF TEST RESULTS <br />MAL <br />Component <br />Pass <br />Fail <br />Not <br />"bested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Spill Box T (:SUPREME UNLEADED premium <br />fill <br />Spill Box T2:REGULAR UNLEADED regular fill <br />X <br />If hydrostatic testing was performed, describe what was dorle with the water after completion of tests: <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledgee,,ttheeffa.,ccts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: Date: 2/3/2014 <br />WO: 2314910 <br />